Light on Anxiety Child Intake Form

Note when working with child/adolescent clients:

Release of Record:

• Parents/legal guardians of children under 12 are legally entitled to obtain record upon request.
• If adolescent client is over 12 years old, adolescent client will have to sign a release of information in order for parents/legal guardians to obtain access to their record.

Collaborating With Parents/Legal Guardians When Working With Children & Adolescent Clients:

Light on Anxiety values collaborative care when working with child/adolescent clients (age 17 and younger) and their family.  When appropriate, Light on Anxiety will share relevant treatment information such as:

• Diagnostic
• Treatment Recommendations
• Services Provided
• Recommended Out of Session Exercises

Note: information to be shared with parents/legal guardians will not include what is directly discussed between the Light on Anxiety therapist and the child/adolescent client unless it includes intent to harm self or others.

Note: Light on Anxiety is in network with BCBS PPO, Blue Choice PPO and Aetna.

Light on Anxiety requires that all clients maintain a credit card on file to cover any balance due after your insurance benefits are applied. For clients who are uncomfortable leaving a credit card on file through our secure billing system, clients can pay at the time of the visit for all services received.

Here’s how it works:

1. We securely save your credit or debit card before or during your visit.

2. If in network, we work with your insurance plan to determine your payment amount for the visit.

3. We process the payment for you automatically and email you the receipt to the email address supplied on the intake form. 

It is recommended that you provide Light On Anxiety with the contact information for all health care providers your child is currently seeing or has seen in the last 6 months in order to incorporate all relevant health information into your child's treatment plan.

If you would like Light On Anxiety to coordinate care with any other individuals or providers on your behalf, please complete an additional release of information.

Note: To ensure progress on intake form is not lost, right click on the link to open the release of information in a new tab/window.

What does child/adolescent treatment look like at LOA and what is required of me? 

LOA values a team based approach where parents play an active role in the treatment plan.  Therefore, it is required that at least one parent attends each appointment.  You will either be actively involved in the whole session or part of the session, depending on clinical recommendations of your LOA therapist but no matter what, your participation will be a key component in the creation and implementation of successful CBT treatment plan for your child so be prepared for hard but important work that will assist your child in moving past stress and anxiety as rapidly as possible.  

What can I expect from initial visit? 

The first 1-2 sessions are devoted to a comprehensive assessment of your problems and the development of a treatment plan.  It is recommended thatthe initial assessment sessions are parents only in order to gather as much pertinent information as possible prior to bringing the child/adolescent to appointments. After the initial assessment is completed, the treatment plan will be reviewed and recommendations will be provided regarding which Light on Anxiety therapist will be the best fit based on clinical needs and scheduling requirements. Note: the therapist who conducts the initial assessment may not be the therapist who provides ongoing treatment, but all initial findings will be throughly discussed and reviewed with the assigned Light on Anxiety therapist.

What will treatment entail?

Treatment will include one or a combination of the following: individual therapy (which can include family members), referrals to a psychiatrist for medication evaluation, specialized exposure therapy or referrals to a physician for medical evaluation. Exposure therapy may occur on a weekly basis, or may be required on a more intensive basis when your difficulties are more severe. All therapy we offer is empirically supported and provided to you because it is the treatment determined to be the most effective in assisting you or your child in overcoming anxiety or anxiety-related conditions.

What is expected of me?

We expect you to come prepared to work hard and play an active role in treatment.  We will serve as your anxiety coach and teach you the skills and provide you with the support to move forward in living a vital life.  But it is up to YOU to do the hard and transformative work of applying these new skills in your every day life.

How frequently will we meet?

A treatment plan will be customized to your needs and therefore, after the initial assessment, your therapist will be able to provide you with a recommendation for treatment intensity.

What if I need to reach you in between sessions?

If you or your child are in a mental health emergency and require immediate assistance, please go to the nearest hospital emergency room and leave a voicemail message for your therapist to notify them of the emergency (312.508.3645).  If you are uncertain how to manage a panic attack or an exposure assignment, you are welcome to leave a message for your therapist on their voicemail. Your Light on Anxiety therapist will get back to you with 24 hours on business days.  If you believe that you need therapy that provides 24 hour crisis management, please discuss this with your therapist and they will help you find a referral to a program that can best meet your needs. 

What is your policy on electronic communication?

For communication between sessions, we only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement.  This means that email exchanges and text messages with the office should be limited to administrative matters.  This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that we cannot guarantee the confidentiality of any information communicated by email or text. Therefore, we will not discuss any clinical information by email or text and prefer that you do not either. Also, we do not regularly check  email or texts, nor do we respond immediately, so these methods should not be used if there is an emergency.

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions.  But if an urgent issue arises, you should feel free to attempt to reach out to us by phone.  We will try to return your call within 24 hours except on weekends and holidays.  If you are unable to reach us and feel that you cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call.  If  we will be unavailalbe for extended time, we will provide you the name of a colleague to contact in my absence if necessary.

Do you accept insurance?

Currently, Light on Anxiety Treatment Center only contracts as an in network provider with Blue Cross Blue Shield of Illinois (BCBSIL) Preferred Provider Organization (PPO), Blue Choice PPO and Aetna. Your insurance will provide a quote of benefits, not a guarantee of payment.  While the filing of insurance claims is a courtesy we extend to our in network clients, all charges are your responsibility from the date services are rendered. Reimbursement varies depending upon the level of benefits that you and your employer have chosen. Your degree of coverage is a matter between you and your insurance company and/or your employer.  Light on Anxiety cannot guarantee that your insurance will cover my services.  You should verify with your carrier that it will be covered and to what extent.  You will be expected to pay all co-payments, deductibles, and for uncovered and ineligible services.  If your insurance company has not paid a claim within 20 days of submission, you accept full responsibility for payment in full for any outstanding balance. 

For clients looking to obtain reimbursement from other insurers, we are happy to submit an out of network claim on behalf of the client to facilitate reimbursement of out-of-network mental health claims.  

Your copay is due at the time of your session. If you do not know your copay amount at the time of session, your therapist will collect the industry standard copay amount of $20 at the time of session and our billing department will make any necesary adjustments upon receiving payment from BCBS.

Your insurance company may require us to contact them to discuss your treatment and progress. We are glad to respond to brief requests for information. In the event that extensive information or written reports are requested, Light on Anxiety staff will contact you to discuss the likely fees associated with providing these services. Insurance companies may have different levels of coverage. 

In addition, if your BCBS member ID begins with CTY we recommend you contact your insurance provider to determine if you need to obtain preauthorization prior to commencing treatment at Light on Anxiety.

For all other insurance plans, clients are responsible for paying Light on Anxiety directly and then Light on Anxiety can electronically submit a paid super bill on your behalf to facilitate obtaining out of network reimbursement.  If you are interested in having Light on Anxiety submit a superbill to your insurance company, please provide your insurance information.

 Do you accept Medicare/Medicaid? 

Light on Anxiety Treatment Center is not a covered provider for Medicare or Medicaid.  Therefore you or your legal representative accept full responsibility for payment of all charges. Usual Medicare limits to charges and services do not apply. By choosing to work with Light on Anxiety, you acknowledge that you completely forego the use of these benefits for your treatment at this center and agree that neither you nor any representative will file any claims to Medicare or Medicaid, nor will you ask the provider to do so.  You acknowledge that you freely enter this contract with the knowledge of your right to obtain Medicare covered services from providers who have not opted out of Medicare, and understand that you are not compelled to enter into private contracts with providers who have not opted out of Medicare.        

How much will treatment cost?

Light on Anxiety strives to make treatment as short term and cost effective as possible.  Light on Anxiety therapists know that it is their job to get you back into your life as quickly as possible.  Fees for light on anxiety therapy services are:

Master Level Clinician: 

30 minute session: $90
45 minute session: $135
60 minute session: $180 

Ph.D Level Clinician: 

30 minute session: $130 
45 minute session: $195
60 minute session: $260
 

Add-on services:

Light on Anxiety staff are available for home visits and other out of office exposure based work, when clinically necessary.  These services are pro-rated in 15’ increments at the therapist’s hourly rate. Travel time to and from the office is included in the total charge.  Light on Anxiety staff are also available via email, text and phone, for between session assistance.   In addition, Light on Anxiety staff is available to consult with other providers and write reports.  These services will also be pro-rated in 15’ increments at the therapist’s hourly rate. These calls may, or may not, be covered by insurance. 
 

What is your cancellation policy?

A fee for the missed session is charged for cancellations with less than 24 hours notice. Charges for missed appointments are not covered by insurance and are your responsibility. 

Are there any limits to confidentiality?

The information you share in therapy is confidential and will not be disclosed without your written permission except when you may pose a danger to yourself or others or as required under Illinois and Federal law.  If we ever suspect you are at risk to harm yourself or others, we are required to report this to the Firearm Owners Identification (FOID) program.  If you disclose information related to suspected child or elder abuse, Light on Anxiety is obligated to report it.  If Light on Anxiety receives a court order signed by a judge to release your information, I am obligated to honor it.

Light on Anxiety Litigation Policy 

I agree that I am here for treatment and that I have been advised that if I need an expert witness in my case, I should hire someone specifically for that purpose.  I understand that my Light on Anxiety therapist will not serve as a witness in any type of litigation.

I agree to advise my attorney that Light on Anxieyy will not become involved in any litigation. I agree that should I seek the Light on Anxiety's involvement in such litigation I will be responsible for Light on Anxiety's attorney fees in consulting an attorney to avoid involvement.

If ordered by the court to participate in the litigation, either in giving a deposition or testifying or if I voluntarily agree the following rules shall I apply:

1.  Fees for time involved in preparing a report(s) for LOA attorney or the court must be paid in advance before such report will be written. 

2.  The fee for LOA testimony or deposition must be for a 3 hour block of time at $900 for the three hours.  Any time exceeding the 3 hours including travel time, shall be billed at the rate of $400 per hour.  Fees must be paid at least one week in advance of the testimony being given.  If not paid in advance, LOA will not appear to give testimony.

3.  If the testimony date is cancelled or rescheduled with less than one business day’s notice, the fee will not be returned or will still be owed. Any further rescheduling will require the payment of  another 3 hour minimum fee. 

Light on Anxiety Child Custody Litigation Policy

I hereby confirm I have brought my child to Light on Anxiety to address his/her mental health issues.  I understand that the role of Light on Anxiety is to treat mental health issues and that LOA will not become involved in any custody or visitation disputes.  I recognize that for my child’s mental health, it is important not to involve the therapist in court proceedings. I therefore agree  that as a condition of treatment for my child, I will not seek to have my LOA therapist testify in court, give a deposition, or an affidavit.  I understand that the therapist will only become involved when the therapist determines it is necessary to protect the child.

I agree to advise my attorney that the treating therapist will not become involved in any custody/visitation litigation.  I agree that should I seek the therapist’s involvement in such litigation I will be responsible for the therapist’s attorneys fees in consulting an attorney to avoid involvement,  and if ordered by the court to participate in the litigation, I agree to pay one week in advance of any court hearing for a minimum of at  least 3 hours of the therapist’s time at the rate of $300 per hour.  I understand that if I seek to involve the therapist, he/she may immediately discontinue care with my child.

Completion of this health consent form is required prior to initiating in person treatment at LOA or entering a LOA office space, in order to maximize health and safety for all.

The threat of COVID-19 is ongoing throughout the United States.  As a way to mitigate the risk of exposure to COVID-19, our practice has transitioned to providing most services via telecommunications technology.  Use of telecommunications technology reduces the need for persons to come into close contact with each other or to be in areas where exposure to COVID-19 may occur.  However, in some situations, tele-therapy services may not be adequate, and in-person services may be more appropriate.

It is important to consider that, although insurance reimbursement for tele-therapy services may have been mandated during the COVID-19 pandemic, such mandates may no longer be in effect, and tele-therapy may no longer be reimbursed by your insurance company.

As COVID-19 regulations continue to evolve, LOA may become legally required to disclose that we have been in contact, especially if either of us were to test positive or show signs of COVID-19 infection. If we are legally compelled to disclose information, we will inform you and will only provide the minimum necessary information (e.g., your name and the dates of our contact) required by law. 

In order for LOA to provide you with in-person services, the following protocols must be followed by patients/clients and providers:  

(1) Hand sanitizer will be provided at the office entrance and must be used upon entering the office.

(2) Social distancing requirements must be met.

(3) Patients and providers will be required to wear face coverings or masks while in the office as long as encouraged by the CDC. Note: If you do not have a face covering, one will be provided to you. 

If at any point during your treatment with Light on Anxiety you become ill, your sessions will be moved to our Web-Based Platform until you have been symptom free for 7 days or can provide a negative test result.  

We remain committed to following state and federal guidelines and to adhering to prevailing professional healthcare standards to limit the transmission of COVID-19 in our offices.  Despite our careful attention to sanitization, social distancing, and other protocols, there is still a chance that you will be exposed to COVID-19 in our office. If, at any point, you prefer to stop in-person services or to consider transitioning to remote services, please let us know.

Benefits and Risks of Telehealth 

Telehealth refers to providing services remotely using telecommunications technologies such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person therapy and telehealth, as well as some risks.

For example:

• Risks to Confidentiality  Because telehealth sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. We will take reasonable steps to ensure your privacy, but it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.

• Data Protection The nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. We will make every attempt to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others.  You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth). 

• Technology Issues There are many ways that technology issues might impact telepsychology.  For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.  

Appropriateness of Telehealth

Usually, we will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work.

From time to time, we may schedule in-person sessions to "check-in" with one another. We will let you know if we decide that telehealth is no longer the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services.

Emergencies and Technology

Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person therapy.  To address some of these difficulties, we will create an emergency plan before engaging in telehealth services.  We will ask you to identify an emergency contact person who is near your location and who we will contact in the event of a crisis or emergency to assist in addressing the situation.  We will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency. 

If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call us back. Instead, call 911, or go to your nearest emergency room. Call us back after you have called or obtained emergency services.

If the session is interrupted and you are not having an emergency, disconnect from the session and we will wait two (2) minutes and then re-contact you via the telehealth platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, call us on the phone number provided to you.

If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.

Fees

The same fee rates will apply for telehealth as apply for in-person therapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance provider does not cover electronic telehealth sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to engaging in telehealth sessions in order to determine whether these sessions will be covered.

Records

We will maintain a record of our session in the same way we maintain records of in-person sessions in accordance with our policies.

Over the past 2 weeks, how often have you been bothered by the following problems: